Background: Acute Aortic Syndromes (AAS) are life threatening cardiovascular emergencies that are the bane of every emergency physician’s existence. They are diagnostic challenges due to the clinical presentation being highly non-specific. Computed tomography angiography (CTA), Transesophageal Echocardiography (TEE), and Magnetic Resonance Angiography (MRA) can help accurately diagnose AAS. CTA exposes patients to radiation and large doses of intravenous contrast, neither of which is a good enough reason to skip the test in patients you think may have a dissection, but certainly not something we want to do to all patients coming to the ED with chest pain. TEE and MRA may not be available or able to be performed in a timely manner. Having a clinical algorithm that can help physicians reduce misdiagnosis and at the same time avoid over-testing are lacking.

What They Did:

Multicenter, prospective observational study

6 Hospitals in 4 countries

Use of the Aortic Dissection Detection Risk Score (ADD-RS) of ≤1 + Negative D-Dimer (DD) for ruling out AAS

Outcomes:

Primary: Failure rate of ADD-RS and D-Dimer neg strategy for ruling out AAS

Calculation: AAS diagnoses/ Number of Patients with Negative DD Within in a Risk Category

Secondary: Efficiency in Ruling-Out AAS

Calculation: Number of Patients with Negative DD Within a Risk Category/Number of Enrolled Patients

Inclusion:

Consecutive patients ≥18 years of age, with any 1 or more of the following symptoms, dating ≤14 days:

Half the patients in this study did not have conclusive imaging and their case follow up was based on 14-day clinical follow up data only

Unclear if 14 day follow up is an adequate time period

There is no comparison to clinical gestalt

Rate of AAD is pretty high (i.e. 13%), making it unclear how this would work in lower risk groups

Only use one d-dimer assay, that may not be available at all institutions

No discussion of age-adjustment of d-dimer

Discussion:

In this paper, the authors suggest the following algorithm:

ADD-RS>1, regardless of DD should proceed to CTA

ADD-RS = 0 or ≤ 1 + DD neg are potentially ruled out for AAS

This strategy will miss around 1 in 300 cases of AAS

Author Conclusion: “Integration of ADD-RS (both = 0 or ≤ 1) with DD may be considered to standardize diagnostic rule-out of AAS.”

Clinical Take Home Point:

This is a novel clinical strategy in evaluating patients with the potential of Acute Aortic Syndromes (AAS), but still requires external validation, for reproducibility and comparison to overall clinical gestalt before implementation into clinical practice.